According to published reports, up to 75% of ED patients present with pain-related complaints, and more than half come to the ED with severe or moderate pain. Pain management is a fundamental component of emergency medicine, but there are barriers to providing effective pain control in the ED. “There is growing tension between the ethical and professional obligations of emergency physicians (EPs) to treat pain and their reluctance to contribute to the growing problems of opioid abuse and diversion,” explains Arvind Venkat, MD.
A more in-depth understanding of how to resolve issues surrounding ethical pain management in the ED may help EPs in their efforts to treat pain. In an article published in Academic Emergency Medicine, Dr. Venkat and colleagues proposed an ethical framework to address the clinical dilemmas surrounding the management of pain in ED patients. “Given the frequency of ED patients presenting with pain and the barriers to effective pain relief, it’s important to recognize the ethical issues that can affect the treatment of pain in this setting,” says Dr. Venkat.
According to Dr. Venkat, EPs often get little training in addiction problems. “It’s important for EPs managing pain to not assume that all patients are at risk for addiction to prescription drugs like opioids,” he says. “We need to recognize narcotic seeking behaviors, but we must also keep the patient’s health foremost in mind,” he says. “If patients are suspected of narcotic seeking behavior, we should treat them but also direct them to resources where they can get more appropriate care for their pain and potential dependency issues.”
A framework needs to be in place to facilitate an effective and appropriate approach to pain management in a variety of circumstances in the ED. Dr. Venkat notes that EPs should not automatically prescribe opioids or other prescription pain drugs to ED patients presenting with pain. “We need to take the necessary steps to better understand the causes of pain,” he says. “We also should look at patients’ history to see how they access care and follow-up patterns. EPs need to become savvy to these issues in order to provide the most appropriate care possible.”
An Important Issue
Defining an ethical framework for providing pain management in the ED is complicated because there is limited knowledge about ED patients and the disease processes that cause their pain. “Interactions between EPs and patient are brief, which limits how effectively pain can be managed in the ED,” Dr. Venkat says. “We need to be empathetic with patients and have forthright communication about ED pain management. We should seek out physician biases and patient motivations for pain treatment in order to optimize the ethical outcomes for both EPs and their patients.”
Venkat A, Fromm C, Isaacs E, Ibarra J, on behalf of the SAEM Ethics Committee. An ethical framework for the management of pain in the emergency department. Acad Emerg Med. 2013;20:716-723. Available at: http://onlinelibrary.wiley.com/doi/10.1111/acem.12158/full
Karwowski-Soulie F, Lessenot-Tcherny S, Lamarche-Vadel A, et al. Pain in an emergency department: an audit. Eur J Emerg Med. 2006;13:218-224.
Ezenwa M, Ameringer S, Ward S, Serlin R. Racial and ethnic disparities in pain management in the United States. J Nurs Scholarsh. 2006;38:225-233.
American College of Emergency Physicians. Clinical Policy: Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Department. 2012. Available at: http://www.acep.org/clinicalpolicies/.
Cordell WH, Keene KK, Giles BK, Jones JB, Jones JH, Brizendine EJ. The high prevalence of pain in emergency medical care. Am J Emerg Med. 2002;20:165-169.